Tag: Clean Claims

Have you ever analyzed how many claims does your practice or center submit to carriers daily? Do you track the percentage of claims that get paid at first submission? Each time carriers deny your claims they accumulate in your accounts. The claims have to be revisited, denials have to be identified, appropriate action has to be taken and the claim cycle begins again. There is a substantial time and resource utilization in doing the submission process all over again. Hence, it is very, very important to get maximum number of claims paid at the first submission.

The average percentage of claims that get paid at the first submission determines the clean claim percentage. It is ideal to keep this percentage high for running a profitable surgery center where resources are tight and time spend is crucial. So how do you ensure optimum percentage of clean claims and build a continuous process?

Here 7 steps that will help ensure clean claims submissions percentage over 95%:

3) Procedure authorization at-least five days prior to the date of service. Information to verify- type of procedure, checking with carriers if a certain scheduled procedure requires a prior authorization and verifying if the procedure is covered under the patient plan type.

4) Follow carrier specific coding guidelines. Information to verify- CPT and ICD compatibility, submission process- paper based or electronic. Create carrier specific Local Coverage Determination (LCD) guidelines to verify coding compatibility. Surgery center can also explore the option of automation the claims scrubbing process by building rules engine software systems or by partnering with other companies providing this service.

The above checklist can be modified and customized to meet your center’s requirements. Slowly build up a process to make these crucial elements a part of your center’s operational flow. Clean claims lead to faster reimbursements and an organized work flow.

They are the scrutinizers. The claim sniffers. They are the auditors. Have you ever thought of why your claims are denied or paid? Is there a really smart computer or a human face behind that hits to go or the no-go button? It’s both. When you submit claims, they go through some really intelligent computer programs. These programs process each claim and flag irregularities. These red flags are then extensively analyzed by claim auditors.

Consequences of audit.
If any discrepancies are detected, auditors deny the claim. In cases where payments have been made, recoupment follows the audit.

Recommendations by auditors.
1. Follow ethical coding guidelines while submitting the claims.
2. Take into account the compliance guidelines laid down by the insurances.
3. Avoid malpractices for higher reimbursements.

As an auditor, before hitting the pay button I think of denial. I look into all aspects – coding, billing, eligibility, benefits and most of the claims have some or the other loophole which helps me deny the claim. I have always been taught – its your check book & you are making the payment on claim.– Anonymous auditor (name withheld)